Rural female veterans' experiences of VA care and a VA telehealth outreach program.

Our study was determined by the San Francisco VA Medical Center (SFVAMC) Research and Development Committee to not constitute human subjects research and was determined to be institutional review board (IRB) exempt in accordance with the Veterans Health Administration (VHA) Handbook. Our study is based on Quality Improvement (QI) activities and was determined by VA to be exempt from institutional review board (IRB) review as the study was determined to not constitute human subjects research. Between September of 2022 and December of 2024, the Boost Program’s nurse practitioner (NP) piloted outreach calls among 5 partnering VA outpatient clinics and successfully completed outreach calls with 543 veterans. Three out of five clinics were designated as being in rural areas by the Rural-Urban Communing Areas (RUCA) and Federal Office of Rural Health Policy (FORHP) definitions, and five out of five clinics served veterans residing in rural counties based on RUCA and FORHP definitions [ 14 , 15 ]. Veterans who had been reached by the Boost NP were cold called and invited to participate in a 30-minute qualitative telephone interview within one year of receiving the initial outreach call. Given that the patient population at VA is predominantly older (median age is 60 + years old) [ 2 ], we over-sampled for younger (under 50-year-old) female veterans. These veterans lived geographically proximal to one of our five partnering VA outpatient clinics housed within one VA regional health care system and represented a mix of semi-urban, suburban, and rural inhabitants. We developed an original semi-structured interview guide for this study and have provided the interview guide as Supplemental File 1. Qualitative researchers (KZ, CM) conducted the 30-minute telephone interviews. Verbal informed consent was obtained from veterans prior to an interview. All interviews were audio recorded for analysis. Interview topics included veterans’ experiences seeking female-specific healthcare services care at VA and experience with the Boost Program outreach call, as well as suggestions for improving female veterans’ healthcare services at VA. Participant age, race, and ethnicity data were collected through chart review of individuals’ VA electronic health record (EHR). Data on race and ethnicity are obtained by the VA in accordance with mandates from the Office of Management and Budget which outlines the use of standards including self-identification of race and ethnicity using the following categories: (1) American Indian or Alaska Native (2) Asian; (3) Black or African American; (4) Native Hawaiian or Pacific Islander; (5) White [ 16 ]. For this study, Veterans who self-reported multiple races were coded as “multiracial” (see Table 1 ). Table 1 Participant characteristics Interviewed (n=21) Age  <30 10% ( n =2)  30-39 14% ( n =3)  40-49 10% ( n =2)  50-59 14% ( n =3)  60-69 19% ( n =4)  70-79 29% ( n =6)  80+ 5% ( n =1) Race  White 67% ( n =14)  Black or African American 0%  American Indian or Alaska Native 5% ( n =1)  Asian 0%  Native Hawaiian or Pacific Islander 0%  Decline 5% ( n =1)  Unanswered 0%  Unknown 5% ( n =1)  Multiracial 19% ( n =4) Ethnicity  Not Hispanic/ Latino 100% ( n =21)  Hispanic/ Latino 0%  Decline 0%  Unanswered 0%  Unknown 0%  Multiple 0% Participant characteristics We used a rapid qualitative analysis approach developed for health services research settings, which allows for qualitative results to be analyzed concurrently with data collection to inform the development and testing of interventions and implementation strategies [ 17 – 19 ]. Guided by our semi-structured interview guide, we created a summary template using Microsoft Excel organized by topical area. A qualitative team member (KZ, CM) listened to each audio recorded interview and populated a summary template by summarizing key points, including participant quotations illustrating main takeaways. To ensure reliability, a second qualitative researcher listened to the same audio-recorded interview and reviewed the primary analyst’s summary for accuracy. To synthesize data, we used matrix analysis, an approach to displaying data to highlight commonalities and differences and to identify patterns and relationships [ 17 , 18 , 20 ]. We created a veteran findings matrix using Microsoft Word organized by domains in the interview guide to compare feedback across participants. Qualitative team members met weekly throughout the concurrent data collection and data analysis phases to ensure consensus of emergent themes, in addition to routinely meeting with the larger study team to discuss preliminary findings.

Twenty-one veterans between the ages of 22–85 years old participated in a qualitative interview (Table  1 ). Three primary themes emerged across 21 veteran interviews: (1) Veterans described how the landscape of female-specific healthcare at the VA has expanded in recent decades, but still has a long way to go; (2) Veterans valued the way the Boost Program outreach calls communicate to them that the VA cares about them and their unique needs, both as female veterans and as rural veterans; and (3) The Boost Program outreach call works against the perception that the VA does not offer female-specific healthcare services. Overall, veterans reported seeing an increase in the availability of female-specific healthcare services in VA in recent decades. Notably, veterans emphasized the establishment of Women’s Clinics as a landmark expansion of female healthcare services in VA. V016 described how the experience of going to Women’s Clinic departs from going to regular primary care where “The average person was a man, white or black, and old… I just didn’t look like the other vets, so at least when it was other women, so there was similarity even though, I mean, it’s every walk of life, but it’s more comfortable.” At the same time, participants highlighted that in addition to system-level changes, they also observed changes on the individual clinician level, with one participant stating “Since [my new PCP] is a female, I think she takes women more seriously than he [my prior PCP] did” (V010). One participant who lived in a rural community, V011, shared how important it was to her to be able to be seen by a female health practitioner at her local VA outpatient clinic, stating: “The older I get the more—I feel more comfortable having a women’s health practitioner… Seriously, I have only wanted a women’s health practitioner since, probably, since I had a baby… I went like [3–4] years because, you know, I didn’t want to have the male physicians or male nurse practitioners, or the PA’s that they had, you know, I was not comfortable dealing with them at all. I would either go without healthcare or I would wait until I could get an appointment through my own insurance.” “The older I get the more—I feel more comfortable having a women’s health practitioner… Seriously, I have only wanted a women’s health practitioner since, probably, since I had a baby… I went like [3–4] years because, you know, I didn’t want to have the male physicians or male nurse practitioners, or the PA’s that they had, you know, I was not comfortable dealing with them at all. I would either go without healthcare or I would wait until I could get an appointment through my own insurance.” While participants valued the increase in female-specific healthcare services in recent decades, they generally commented that VA is still lacking in providing comprehensive care for female veterans across varied life stages. Participants noted that while the higher number of nurse practitioners (NP) at VA makes some routine female healthcare available (e.g., pap smears), other forms of routine care such as mammograms, bone density tests, or specialty fertility care are still largely outsourced to non-VA community-based clinicians. Given this, V013 emphasized the need to make all female health care provided within VA (e.g., nutrition, in vitro fertilization, menopause care), stating “I think anything with regard to women’s health should be in the forefront.” V013 added that doing so would be ideal both financially (e.g., instead of reimbursing community-based clinicians) and by providing improved continuity of care for female veterans, concluding: “In addition to us not having to jump through hoops… the [VA clinicians] who are reading the x-rays [from community care clinicians] are getting reimbursed nil – financially it would make more sense.” Participants described the outreach calls as communicating to them that the VA cares about their needs as female veterans, with veterans stating: “It’s nice to have someone that actually sounds like they’re taking an interest in what you need” (V006) and to help ensure that “my requests are taken seriously” (V013). Several veterans reported feeling appreciative that someone at the VA was reaching out to them, asking about their experiences, and asking for their feedback. Participants found the outreach call to be beneficial, with V020 stating “I felt supported. I felt the NP knew the system well and could help me. I was reminded my service mattered and my health did too to the VA.” Other participants shared that the outreach calls were helpful for increasing their knowledge about what services are available to female veterans at VA, which in numerous cases they had not known existed or not known they were entitled to. Participants characterized receiving the initial unscheduled and unexpected call from the Boost NP as a surprise, but generally as a pleasant one. They felt the call signaled to them that the VA cares about female veterans. As one participant shared, “I was actually elated… because it’s the VA’s job to make sure that we’re getting adequate care, so, to get a blind phone call asking where we could improve, that’s just positive” (V013). V004 shared that she appreciated being asked her opinion of her care during the outreach call, and V007 similarly spoke to her appreciation that the VA is making care not only for female veterans a priority, but also for rural veterans. V007 elaborated: “I was pleasantly surprised that the VA has made care up here for veterans a priority because it is so rural up here and there is not a lot of options. You know, the healthcare up here in general has been really super frustrating… Speaking to [the Boost NP] … felt like a breath of fresh air as I was like, wow, they actually care and are trying to help. It’s awesome the service that’s being provided.” “I was pleasantly surprised that the VA has made care up here for veterans a priority because it is so rural up here and there is not a lot of options. You know, the healthcare up here in general has been really super frustrating… Speaking to [the Boost NP] … felt like a breath of fresh air as I was like, wow, they actually care and are trying to help. It’s awesome the service that’s being provided.” Participants also emphasized the importance of receiving the outreach call from a clinician, rather than from someone calling only to set up an appointment. As a retired nurse, V015 shared being impressed that a nurse practitioner was making the outreach calls and that follow-through on the care discussed was important to her. V015 explained: “Maybe because I’m a nurse, knowing that the VA cared enough in a sense to have a nurse call and ask the questions if I was receiving what I was needed and so forth. That to me was very important. … It said to me that you guys care. And that was important, it was very important to me.” For numerous participants, the experience of receiving a call from an NP who could deliver care in real-time during the outreach call (e.g., attend to medical needs and arrange specialty care if needed, refill medications, order routine preventative wellness screenings) came in contrast to prior experiences seeking care. Given this, participants emphasized that the outreach calls can help veterans access needed care sooner rather than later. Veterans shared prior experiences of having difficulty scheduling timely appointments, as V012 shared: “It’s hard to get scheduled, to get in, a lot of times and, I know a lot of times when I needed immediate help I was scheduled 6 weeks out sometimes” (V012). Similarly, V008 reflected: Sometimes it’s just nice knowing that someone’s kind of taken the time to reach out to you, instead of sometimes you having to be the one constantly trying to reach out and not getting a response or getting help back, so it meant a lot to me because sometimes when I reach out – sometimes you don’t get a call or a response back for months or weeks or days. And so, being able to just get a call was nice, made it easy. Surprising, but I actually liked it. Sometimes it’s just nice knowing that someone’s kind of taken the time to reach out to you, instead of sometimes you having to be the one constantly trying to reach out and not getting a response or getting help back, so it meant a lot to me because sometimes when I reach out – sometimes you don’t get a call or a response back for months or weeks or days. And so, being able to just get a call was nice, made it easy. Surprising, but I actually liked it. Relatedly, multiple participants spoke highly of the personalized nature of the Boost NP’s care in contrast to prior experiences of having difficulty accessing care. V007 stated: “So many times in the healthcare field it’s really easy, unfortunately, to feel like a number and not a person. It’s one of the aspects that I really appreciate about this program, is that it is very personalized and individualized for us, for our healthcare, and what we need.” Another participant similarly emphasized the importance of feeling as though the Boost NP took the time to listen, as well as act on, her concerns, stating: “I feel like she actually cares about the patients, so that was refreshing. There’s other times I feel like, you kind of just get moved through… I appreciate that she took the time to talk to me and actually listen, like, put in referrals and stuff to get me seen, because I was having trouble just getting anyone on the phone even let alone an appointment. So, she helped a lot” (V002). “I feel like she actually cares about the patients, so that was refreshing. There’s other times I feel like, you kind of just get moved through… I appreciate that she took the time to talk to me and actually listen, like, put in referrals and stuff to get me seen, because I was having trouble just getting anyone on the phone even let alone an appointment. So, she helped a lot” (V002). One participant, V011, concluded: “With [the Boost NP’s] intervention things happened, and so I felt like things were under control”. Many participants touched on the perception that the VA does not focus on offering female-specific healthcare services. Even with the increase of Women’s Health-trained PCPs throughout the VA, several participants shared not having been informed of the female health services available to them by their VA clinicians. In one example, when asked if her PCP at her local VA outpatient clinic had informed her about what female health services are available to her, V008 responded “No, I’ve never been talked to about it.” Participants also spoke to the challenges of accessing VA care as female veterans with young children. In response to one participant’s, V007, referral to a surgical procedure at the nearest VA medical center over 5 h away from her home, V007 explained that receiving the surgery in her local community through a community care referral would be much more appropriate given her many responsibilities at home. V007 continued that in lieu of a community care referral, the VA should assist with reimbursements for traveling to the medical center. V007 elaborated: “I don’t know how much money the VA has to be able to do things for people. And I know I am kind of like the odd participant because I’m not an old man. Cause the typical veteran is an old man, right? So, my situation, my circumstances are different because I’m younger and all the kids I have and whatnot. But I’m still a veteran and I can still participate. So maybe just like for the people like me, like the unusual participants… maybe if there are special circumstances like financial hardship or children with disabilities, like gift cards maybe, a free hotel voucher, or a gas card. If we’re going to get denied the care that we want where we live… and we are going to be forced to go out of that area with our family… the VA should be helping to make it happen… Or reimbursement too, if I keep the receipts.” “I don’t know how much money the VA has to be able to do things for people. And I know I am kind of like the odd participant because I’m not an old man. Cause the typical veteran is an old man, right? So, my situation, my circumstances are different because I’m younger and all the kids I have and whatnot. But I’m still a veteran and I can still participate. So maybe just like for the people like me, like the unusual participants… maybe if there are special circumstances like financial hardship or children with disabilities, like gift cards maybe, a free hotel voucher, or a gas card. If we’re going to get denied the care that we want where we live… and we are going to be forced to go out of that area with our family… the VA should be helping to make it happen… Or reimbursement too, if I keep the receipts.” Beyond availability of services, several veterans also shared experiences of feeling as though they don’t “count” as a veteran or of people assuming that they are not veterans because they are female. One participant, V011, described having had people ask her if she was a veteran when she was clearly in line for a service at a VA clinic. V011 added seeing phrases such as “thank you for your service” being said mostly to male veterans, concluding: “In some ways we can be invisible.” Relatedly, V003 shared that she doesn’t always feel like she “counts” as a veteran because she was discharged early in her military service period. Emphasizing a need for female-specific support groups at VA, V003 stated that the VA needs to establish more programs that offer female veterans ways to connect and feel a sense of belonging with one another. Participants generally expressed the view that services for female veterans need to be expanded by the VA. For example, participants emphasized the need for female-specific mental health support groups for various concerns and across different life stages that can include groups for endometriosis, menopause, military sexual trauma, groups for grief, and groups focused on aging (e.g., a senior exercise group for female veterans). Another participant highlighted the need to better disseminate information about female-specific healthcare services that are already available in the VA. V008 reflected: I guess I never really get that [form of care] from the VA, or, it never crosses my mind to go to them for that. When I have my appointments and stuff it’s never talked about, and that’s been a lot of my health issues in the last year and a surgery I had… when I tried to talk to them about hopefully getting it covered or anything like that, or them doing it, it really didn’t get touched on, and so I ended up having to pay out of pocket for it… I tried to schedule an appointment with them and it just never happened. I guess I never really get that [form of care] from the VA, or, it never crosses my mind to go to them for that. When I have my appointments and stuff it’s never talked about, and that’s been a lot of my health issues in the last year and a surgery I had… when I tried to talk to them about hopefully getting it covered or anything like that, or them doing it, it really didn’t get touched on, and so I ended up having to pay out of pocket for it… I tried to schedule an appointment with them and it just never happened. Across the board, participants also highlighted the importance of continuously promoting the Boost Program and the services the program provides for female veterans. Recommendations included the distribution of flyers, pamphlets, brochures, and mail-outs, with veterans emphasizing that they would notice any program or service specifically for female veterans.

Female U.S. veterans are the fastest growing segment of Veteran’s Health Affairs (VA) users, comprising 11.3% of veterans in 2023, and this number is projected to grow to 17.2% of veterans by 2043 [ 1 , 2 ]. Female veterans comprise a younger patient population within VA, with a median age of 52 in 2023, compared to the median age of 62 for veterans overall [ 2 ]. While improved access to care for female veterans has been made a VA priority, female veterans still underutilize VA healthcare services relative to male veterans [ 3 ]. In one study on female veterans’ utilization of VA services, 19% of female veterans reported delayed healthcare or unmet care needs, with higher rates of delayed or unmet care needs among younger female veterans [ 3 ]. Furthermore, histories of military sexual assault were predictive of delaying or going without care [ 4 ]. In response to the increased need for female-specific healthcare services, the VA established Women’s Clinics within its major medical centers located in urban centers as well as expanded its Women’s Health training to over 5,000 primary care providers (PCPs) across the healthcare system [ 5 , 6 ]. While VA healthcare services for female veterans have expanded in recent decades, studies have shown that female veterans report barriers to accessing VA care across numerous domains. Some barriers to care include those reported by veterans broadly (e.g., transportation difficulties, financial concerns, inability to take time off work, poor communication about eligibility criteria and enrollment processes, and poor coordination and referral to community-based clinicians) [ 3 , 7 ]. Importantly, female veterans also report female-specific barriers, including the limited availability clinicians trained in female healthcare services [ 8 ], psychosocial factors such as availability of childcare [ 7 ], and perceptions that VA clinicians are not sensitive to female-specific healthcare needs [ 3 , 9 ]. Female veterans have also noted that the VA’s high concentration of male patients can elicit a range of emotions including discomfort, anxiety, and feelings of mistrust, particularly among female veterans with a history of military sexual assault [ 10 ]. Similarly, female veterans report concerns regarding harassment in healthcare settings as an additional reason they might avoid care [ 7 ]. In a study on experiences of harassment within VA healthcare settings conducted across 12 VA medical centers, researchers found that 1 in 4 female veterans reported inappropriate or unwanted comments or behavior by male veterans on VA campuses. Veterans who reported harassment were more likely to report not feeling safe and to delay or miss care, and less likely to report feeling welcome at VA [ 11 ]. While studies have described barriers to accessing VA care, few studies have examined the perspectives of female veterans regarding interventions that can cultivate a more welcoming and safer environment for accessing care. While the expansion of female healthcare services in VA has resulted in increased patient satisfaction in VA primary care settings, the same trend has not yet been seen in specialty care settings [ 5 ]. Female veterans report feeling as though VA specialists disregarded or diminished their concerns and note differences in care experiences based on whether the clinician was female or male [ 5 ]. In a study on female veterans’ experiences of pregnancy-related healthcare visits in the VA, participants described a spectrum of positive and negative experiences; some participants reported positive experiences such as feeling respected and receiving education, but nearly all participants reported negative experiences, including perceived judgment and a lack of continuity of care from clinicians [ 4 ]. Issues related to accessing appropriate female-specific healthcare services are often amplified among veterans who reside in rural communities. Barriers reported by rural female veterans include challenges related to accessing VA facilities and poor communication about eligibility and enrollment processes [ 8 ]. In a study on rural female veterans and their mental health care needs, barriers to care described by female veterans also included feeling stigmatized by clinicians or other military personnel, experiencing a lack of interest from their clinicians in hearing their stories, and the feeling that they were not really seen as a combat veteran despite serving in combat units [ 12 ]. While studies demonstrate that rural female veterans experience greater barriers to accessing female-specific healthcare, studies have not yet shown how novel care delivery innovations can be leveraged to provide tailored care to rural female veterans. We conducted a qualitative study as part of a larger quality improvement project that evaluated the Boost Program, a pilot clinician-delivered telehealth outreach program aimed at improving access to and engagement with VA services among rural female veterans. The Boost Program was fully described in a previous paper [ 13 ]. We examine perceptions and experiences of VA care among rural female veterans, views of a pilot VA clinician-delivered telehealth outreach program for female veterans aimed at using a tailored approach to bridging gaps in care, and recommendations for VA programming.

While VA priorities include continued expansion of healthcare services for female veterans, our findings highlighted multiple areas in which services for rural female veterans can be further enriched. Clinician-delivered telephonic outreach by a trained clinician who has both clinical and system-based knowledge serves to educate and empower veterans to access and utilize VA resources that they might not otherwise know about. Taken together, early data from this clinician-delivered outreach program suggest that the program will have positive impacts on primary care empanelment and more timely and efficient provision of VA resources. Next steps include further inquiry into how clinician-delivered outreach impacts utilization of community care as well as how this model of care can be scaled nationally across the VA.

In this qualitative study on perceptions and experiences of VA care among rural female veterans, participants described the overarching view that while the landscape of female-specific healthcare has expanded at the VA in recent decades, it still has a long way to go to providing comprehensive care for female veterans. Given this, participants reported valuing the way the Boost Program outreach calls communicated to them that the VA cares about them and their needs, both as female veterans and as rural veterans. Our findings suggest the importance of developing pathways for both linking female veterans with the healthcare they need across life stages and educating them about the services already available to them. Prior research has shown that while barriers to care such as financial concerns delay accessing care [ 21 ], positive perceptions of VA care and perceived eligibility for VA services increase the likelihood of seeking mental health treatment among female veterans [ 22 ]. One study has also demonstrated that tailored, personalized, and innovative care models can facilitate pathways to accessing care for female veterans, including approaches that emphasize communication, coordination of care, and sex-sensitive approaches [ 23 ]. Our findings build on this prior research by examining how personalized, clinician-delivered outreach can improve perceptions of, knowledge about, and engagement in VA care. In related work on female veterans’ care experiences in VA, Carlson et al. [ 24 ] described how health education, trauma-sensitive communication, and higher ratings of clinicians’ communication skills are associated with higher likelihood of female veterans reporting trust in their VA clinicians. Our finding that female veterans valued the way the Boost NP reached out to them and listened to their concerns expands on this prior research by demonstrating that a clinician who provides real-time care and counseling can help link female veterans to specific VA services, contributing to improved trust in VA clinicians. Female veterans’ experiences of harassment at VA healthcare facilities have only recently begun to be examined systematically. In a study by Klap et al. [ 11 ], approximately 1 in 4 female veterans reported inappropriate or unwanted comments/behavior by male veterans on VA grounds, and those who reported experiences of harassment were less likely to report feeling welcome and more likely to report delaying or missing care. By providing care over the phone or through telehealth, the Boost Program effectively bypasses logistic and emotional barriers to accessing in-person care at VA facilities. We suggest that clinicians and researchers based in VA facilities who care for female veterans explore implementing and evaluating similar clinician-delivered, telehealth-based outreach programs at their facilities. This work has implications for the expansion of services for female veterans in the VA. Specifically, this work highlights the importance of telephonic outreach to rural female veteran populations to demonstrate VA’s investment and care in their healthcare needs. Thus, a strength of this study is that it can inform clinics in the VA and elsewhere about ways to improve health education and access to care among rural female veteran communities. This study has several limitations. Findings may not be transferable to other regions within the VA healthcare system. Our study also recruited VA outpatient clinics that serve veterans who reside in rural counties; thus, our results might not be transferable to clinic settings in urban areas or to non-VA settings. The VA differs from other settings in several ways, including generally longer wait times for appointments and a predominantly older and male patient population. However, we identified a wide range of factors consistent with research in other rural primary care settings (e.g., transportation challenges) [ 25 , 26 ].

Supplementary Material 1. Supplementary Material 1.